P - 80786� REQUEST FOR ELECTRICAL INSPECTION
Q—C754-652 [�5 Minnesota State Board of Electriciry _
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104-2993
(651) 642-0800 www.electricity.state.mn.us � : -'
Home Duplex Apt. Bldg. Other: New Addn
Commercial Industrial Farm Remod Repair
Air Conditioner Htg. Equip. Water Htr. Load Mgmt. Other:
Dryer Range Elect. Heat Temp. Service
X" above the work covered by this request. Enter remarks in this space and on the back ot tne wnite copy onry.
NSP SAVER'S SVWTCH IIV�T'ALLATI�N
Calculate Inspectic
�ther Installations
Mobile Home Park Stall
Street Ltg. / Traffic Sig.
Transformer/Ge�erator
Sign / Outfine Ltg. Xfmr.
Alarm/Remote �rVipl.�
Fee - This Inspection Request will not be
�e # Service Entrance Size Fee
0 to 200 Amps
Above 200 Amps
INSPECTOR'S USE ONLY
witnout tne correct fee.
Cirouits / Feeders
0 to 100 Amps
Above 100 Amps
TOTA� a
..............� . __. - - -- ,a
1 hereb certity that I inspected the electrical installatlon described herein on the dates stated:
Irrigation Boom Rough In Date
x Special Inspection �e�-
Investigative Fee � �aJ '�ZZ— a �
THIS INSTALLATION MAY BE ORDERED DISCON ED IF NOT COMPLE7ED WITHIN 18 MONTHS.
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OFFICE USE ONLY This request void 18 monMs from validation date printed in this box.
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Request Date Rough-In inspection required? ❑ Yes � yp InsQection Other Than Rougldn: � Ready Now � Will Call
�,�� You must call the inspector when readyf� Date Ready: A
I, []9icensed contractor ❑ company ❑ owner hereby request inspection of the above electrical work at:
Jo�s (Street, 9p. p�qytp�N� � City ���Y Zip Code�.�a1
1 AYLCJK
Section No. Township Name or No. Range No. Fire No. County �
• � ' �
�'�: �
��er� r4fFiit�.aG.t3.. iNC.
Mailin Address (Contractor, Company or Owner P�
i2�67 8� AVE S. SAVAG
Authorized Signature (Contractor, Company or
EB-00001A-12 5/1999 �E99AFtD COPY
Phone No. (�12�7��'�
�
Lic. No. (Plant Elect. Only)
(Q92j941-�712 ! (092j8�}-35'�
Phone Number
\ 1
SEE INSTRUCTIONS ON BACK OF YELLOW COPY